A Day in the Life of a Patient: Why Can’t We Do Better?

Is there a patient who goes through a hospitalization who does not have stories to tell about the obstacles, errors, and indignities that they endured? I just wonder sometimes.

A family relative was hospitalized this week with a stroke at a hospital a few hours from me—and his experience left me demoralized about medicine.

Joe (not his real name) is an 82 year old grandfather, father, husband, and one of a kind. He has a scraggly beard and ponytail. He possesses an artistic spirit, but is punctual to a fault—always early, never late. He has an integrity that is rare these days, which led to a loyal following in business and life. And yes, he is devoted to his family.

On Tuesday, he developed some difficulty with his balance. His wife of over 60 years was worried and brought him to the doctor. That is when the issues began.

Issue #1. His doctor fit him into her schedule and recognized the possibility of the early signs of stroke and sent him for an MR imaging study of his brain. And she also gave him an aspirin, which he promptly took. The problem is that the MR study revealed a small bleed in his brain—and the last thing you want to give someone bleeding in his brain is an aspirin because it can cause more bleeding.

Issue #2. At one of the nation’s most reputable New England hospitals he was evaluated in the Emergency Department and admitted to the hospital. He is brought upstairs to the stroke ward fairly late and he is exhausted. Even later he is told that he must have a CT scan of the brain. He is stable. His symptoms are not changed. Nevertheless, someone orders a CT scan. There was no discussion about whether he should have the scan with Joe’s family; they were told he needed to have one. After the scan, his family is told that the scan will not be read until the morning when the radiologist arrives. They push and are told that the technician looks at the scan and would let someone know if it looked abnormal. They push a little more and ask that they speak to someone who is managing his case. A resident arrives and tells them that there is nothing alarming. The family asks if it will be compared with the scan from earlier in the day (as that was the reason they took the scan 6 hours later) and are told that scan hasn’t been uploaded yet, even though it was with Joe’s records when he was in the Emergency Department. They ask the resident to retrieve it from the emergency room and make the comparison. Finally they are told that the Radiologist in the ER reviewed it—but when they ask who reviewed it, they are not told a name.

Issue #3. It is now even later still on Tuesday (well, past midnight so early Wednesday) and Joe is ready for some sleep. His nurse comes by and feels it necessary to do some education. She tells him that he probably will not be able to drive for a while and might have difficulty getting around. It is not clear why that shocking news needs to be delivered at that moment. It’s not like he is about to jump in a car and drive himself home. Then she hands him a pamphlet about stroke. The family starts reading the book, hoping for some insight about what is happening. The book is simplistic, but does say that bleeding strokes are very dangerous and cause many deaths. This information, provided in the middle of the night and without further information, provokes a lot of anxiety, making it difficult for Joe and his family to sleep. They are now worried that he will die. Education may be good, but the book’s message is not really relevant to Joe’s condition at that moment. It feels like there is some check-box that needs to be ticked that conveys that the patient received education. You can imagine the nursing notes documenting that the education task was completed.

Issue #4. The next day an intern comes in early and examines Joe. A few hours later an entire team stops by and nods their heads. The senior physician explains that they want to observe Joe during the day and get him started with physical therapy. The importance of physical therapy is emphasized. A member of the team promises to come by at 2 pm and to talk with other members of the family. He never returns. No other member of the team stops by during the rest of the day. No doctor has spent more than a few minutes with him except for someone that the family arranges to come by through a personal connection I made. That doctor is kind and thoughtful, but introduces a diagnosis that was never mentioned by the morning team. No doctor comes in after that. The family is unsure all day whether they will see a doctor. The plan for the day is never quite clear. Overall, the day is consistent with a recent study that says that doctors in training spend just 8 minutes a day with their hospitalized patients.

Issue #5. The family waits for physical therapy all day, but no one comes by their room and no information about it is conveyed. By late afternoon, the family checks with the nurse to ask about the consult. The family is told that the physical therapy team is very busy, and they will get to him when they can. Physical therapy never shows up and there is no explanation from anyone about it. Until very late the family is hopeful that someone will start the rehabilitation since the attending doctor emphasized its importance and said that someone would.

Issue #6. It’s late. Joe and his family, who have not left his side, are tired. Someone comes to the room and says it is time for another CT scan. This news surprises them as they were told the CT scan was going to happen the next day—though they were never told why so many scans are necessary, as Joe’s condition is stable. Joe is compliant and heads down to radiology. The exact same scenario from the night before ensues. No one is available to read the scan.

Issue #7. The day is ending. Time for sleep. When I asked the family when Joe will be sent home, they said that they do not know. No one has talked with them about that yet, but they think that maybe it will be tomorrow. They are not sure.

At this point, Joe has been in the hospital only about 24 hours and he has experienced a medical error, poor communication, lack of empathy, broken promises, (perhaps) excess radiation and testing, and delayed interpretation of studies.

Fortunately and remarkably, he is doing fine and hoping to get home. The nurses have helped. They exude a certain grumpiness and a sense of being overworked and uninspired, but they clearly are the ones who make the place run. They are about the only medical staff that Joe sees.

The problem is that nothing about this saga feels exceptional. The system is just poorly designed to provide error-free, compassionate care for the patients and their families. The medical teams accomplish their tasks, but rarely pause to perceive what the patients are experiencing—and to reflect on how they can ease the journey of their patients.

Our path toward improving healthcare is to see through the patient’s eyes and feel their experience. When we do, the world of opportunities to do better opens up to us.

Joe’s day was hard enough when he developed the stroke—the healthcare system should be doing all it can to make things better for him. There are people who are exceptions and demonstrate engagement and compassion—who ensure that services are done well and with a positive attitude—and contribute to a healing environment. But why does that have to be exceptional?

Harlan Krumholz, MD, is a professor of cardiology, epidemiology, and public health at the Yale University School of Medicine and director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. He also serves on numerous cardiovascular care committees for national organizations, including the American Heart Association and the American College of Cardiology and is an elected member of the Association of American Physicians, the American Society for Clinical Investigation, and the Institute of Medicine. He has published more than 500 articles and is the author of the book, “The Expert Guide to Beating Heart Disease.”

About The Author

Physicians Weekly

Harlan Krumholz, MD

Harlan Krumholz, MD, is a professor of cardiology, epidemiology, and public health at the Yale University School of Medicine and director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. He also serves on numerous cardiovascular care committees for national organizations, including the American Heart Association and the American College of Cardiology and is an elected member of the Association of American Physicians, the American Society for Clinical Investigation, and the Institute of Medicine. He has published more than 500 articles and is the author of the book, “The Expert Guide to Beating Heart Disease.”

Related Posts

2 Comments

Alan Vogenberg, RPh on October 8, 2013 at 9:34 pm

Several years ago a Physician friend of mine who was the Medical Director of a local hospital was admitted to HIS hospital. The scenario was about the same as was repotted by Dr. Krumholz. All of this occurred even though this was an “important” patient. Something that Dr. Krumholz did not mention was meals. The Medical Director was in bed, but unable to feed himself. Dietary brought the food, placed it on the table, and left. About 1/2 hour later, she came back. “You didn’t eat anything”, picked up the untouched tray and left. Needless to sat the Physician was furious, but behind his back, Nurses I worked with laughed. For them this was something that always happened.

The issues are repeated to almpost every hospital patient, because it is an assembly line type of set up. #1 The primary care is merely the entry to the assembly belt. The primary care is sure that “somebody” will care for the patient,maybe the specialist, and “they” will let her know how things are going, and will not learn that the ASA was not the thing to do. The lack of cordinated care is a huge problem,as there is no one advocating for the patient. It is cookbook recipe treatment,with CT scans every 6 hours and “call meif you need me”. The hospitalist has many people to see, and has never seen most of them, just does the ” band-aid ” part and hopes it is the right thing. And hopes that “somebody”will let him know if things turn out ok. The nurses do what their checklist demands and hope that “somebody” will watch after this poor man, but given the high mobility of nurses and lack of continuity of care, may not be in charge of getting the right care for the right patient, nor advocate for his needs. The ancillary personnel do what is on their list if nothing else comes their way, but re-hab is not an emergency and it will wait till tommorrow…if “somebody” in PT has time…